<div id="content">
    <section class="main padder">

        <!-- booking table -->
        <div class="panel-body">
            <form class="form-horizontal" method="post" data-validate="parsley" action="<?php echo $form_url; ?>" enctype="multipart/form-data">      

                <div class="form-group">
                    <label class="col-lg-3 control-label">Bank</label>
                    <div class="col-lg-9">
                        <select name="pay_bank" id="pay_bank"  class="form-control small" >
                            <option value="SCB" <?php echo isset($pay_bank)&&$pay_bank=='SCB'?'selected="selected" ':''; ?>>ธนาคารไทยพานิชย์ (SCB)</option>
                            <option value="KBANK" <?php echo isset($pay_bank)&&$pay_bank=='KBANK'?'selected="selected" ':''; ?>>ธนาคารกสิกรไทย (KBANK)</option>
                            <option value="BBL" <?php echo isset($pay_bank)&&$pay_bank=='BBL'?'selected="selected" ':''; ?>>ธนาคารกรุงเทพ (BBL)</option>
                            <option value="KTB" <?php echo isset($pay_bank)&&$pay_bank=='KTB'?'selected="selected" ':''; ?>>ธนาคารกรุงไทย (KTB)</option>
                        </select>

                    </div>
                </div>
                <div class="form-group">
                    <label class="col-lg-3 control-label">Slip Code</label>
                    <div class="col-lg-9">
                        <input id="slip_code" type="text" class="form-control small" name="slip_code" value="<?php echo isset($slip_code) ? $slip_code : ''; ?>" data-required="true">
                    </div>
                </div>
                <div class="form-group">
                    <label class="col-lg-3 control-label">Pay Date</label>
                    <div class="col-lg-9">
                        <input id="pay_date" type="text" class="combodate form-control" data-format="DD-MM-YYYY HH:mm" data-template="D / MMM / YYYY    HH : mm" name="pay_date" value="<?php echo isset($pay_date) ? $pay_date : ''; ?>" data-required="true">
                    </div>
                </div>
                <div class="form-group">
                    <label class="col-lg-3 control-label">Application ID</label>
                    <div class="col-lg-8">
                        <input type="text" name="application_id" placeholder="Application ID" data-required="true" class="form-control"
                               value="<?php echo isset($application_id) ? $application_id : ''; ?>">
                    </div>
                </div>
                <div class="form-group">
                    <label class="col-lg-3 control-label">Active</label>
                    <div class="col-lg-8">
                        <div class="checkbox">
                            <label class="checkbox-custom">
                                <input type="checkbox" name="is_active" value="1" id="is_active" <?php echo isset($is_active) && $is_active == '1' ? 'checked="checked"' : ''; ?> >
                                <i class="icon-unchecked"></i>
                                Active
                            </label>
                        </div>
                    </div>
                </div>

                <div class="form-group">
                    <div class="col-lg-9 col-lg-offset-3">                      
                        <a href="<?php echo base_url('backend/payment'); ?>" class="btn btn-white">Cancel</a>
                        <button type="submit" class="btn btn-primary">Save changes</button>
                    </div>
                </div>
            </form>
        </div>
        <!-- / booking table -->
        <div class="spacing-bottom"></div>
    </section>
</div>